Carotid endarterectomy with adjunctive cephalad carotid stenting: Complementary, not competitive, techniques

Stenosis of the cephalad internal carotid artery (ICA) can present a challenge, making it difficult to obtain a technically satisfying distal end point during endarterectomy. Surgical revision of distal defects can be difficult and yield unsatisfactory results. The purpose of this review is to evaluate the efficacy of intraoperative carotid stenting as an adjunct to endarterectomy to salvage technical defects identified at the cephalad ICA endarterectomy site.

Between January 2001 and February 2008, 14 patients were found to have technical defects located at the cephalad ICA endarterectomy site on intraoperative completion arteriogram. All defects were treated with adjunctive carotid stenting. Patient age ranged from 53 to 84 years (mean, 69 years). Indications for surgery were asymptomatic stenosis (nine), amaurosis fugax (two), and cerebrovascular accident (three). Operative time ranged from 2 to 5 hours (mean, 2.5 hours). Cervical block was used in all but two patients who received general anesthesia.

Technically satisfying results with stenting were achieved in all 14 patients. One patient suffered a perioperative transient ischemic attack; however, neurologic symptoms were noted before placement of the stent in this patient. There were no stent-related complications. All stents remained patent on duplex follow-up averaging 18 months.

Intraoperative salvage carotid stenting is an effective and safe adjunct to endarterectomy when unsatisfactory technical defects are identified at the cephalad ICA endarterectomy site.